Outcomes as
an indicator of quality of care have become increasingly important in the past
decade. Assessment of patient satisfaction reflects care from the patient’s viewpoint.The
development of valid and reliable instruments to measure patient satisfaction
is the first step in continuously improving patient care.

Satisfaction is a part of outcome quality, in addition to
clinically orientated 'traditional' outcomes (e.g. mortality), economic
measurements (costs) and healthrelated quality of life, and has become an
important endpoint in outcomes research (Cleary et al. 1988; Orkin 1999). The
concept of satisfaction is complicated, and influenced by cultural, socio-demographic,
cognitive and affective components (Aharony et al. 1993). Many theories include
patients' expectations as the basic concept of satisfaction (Calman 1988;
Thompson et al. 1995; Wu et al. 2001). A traditional definition of satisfaction
is therefore the degree of congruence between expectation and accomplishment
(Pascoe 1983). Consequently, the involvement of patients in the development of
an instrument to measure satisfaction is very important and must be an integral
part of development. Unfortunately, most instruments have not considered this
aspect and are therefore of questionable value (Le May et al. 2001). This has
contributed to the poor reputation of patient satisfaction as an indicator of
the quality of healthcare services (Westbrook 1993).

From surveys of the US and Europe that consciously adopted the
patient's perspective, we know that patient satisfaction is primarily
determined by aspects such as 'respect for patients’ values', 'information',
‘coordination and continuity of care', 'physical comfort', 'emotional support',
and 'involvement of family' (Allshouse 1993; Delbanco 1992). This has also been
shown when measuring patient satisfaction with anaesthesia care in European countries
(Auquier et al. 2005; Heidegger et al. 2002).

Measuring patient satisfaction requires the application of a valid
and reliable method of measurement. Only a high quality psychometric instrument
will be able to generate high quality data (Avis 1997; Roberts et al. 1987).
Most instruments used are questionnaires that are completed by the patients
themselves. This technique allows surveys with (relatively) higher numbers and
a lower budget than face-to-face or other personal interview methods. For this quantitative
research, usually highly standardised instruments are applied. Qualitative
interviews are of great importance in the phase of generating instruments in order
to evaluate all relevant aspects. This approach is, however, (usually) too
expensive for broad-based data collection.

Content validity: All relevant aspects of satisfaction need to be
included in the questionnaire, integrating patient and expert views, and
evaluation of the state of the art for similar constructs. Focus groups with
patients who have already gained experience with healthcare, help to collect items,
assure content validity and avoid relevant parts of patient perception of care
from being omitted. An evaluation of the ‘state of the art’ considers and
incorporates aspects from other studies measuring similar constructs, if
appropriate.

Criterion-related validity: Aspects, which are related
statistically to central outcome parameters such as overall satisfaction show
criterion-related validity - in a causal interpretation also called predictive
validity.Thus, items and scales believed to assess an important aspect of
patient satisfaction must demonstrate such a relationship in terms of a correlation
to a central outcome parameter.

Construct validity: Construct validity is the extent to which a
measure 'behaves' in the same way as the construct it represents (DeVellis
1991). An important point is whether the relevant aspects are translated in a
comprehensive way into questions which truly measure them. Questions simply
relating to overall satisfaction are inadequate; patient satisfaction should be
measured multi dimensionally using a multi-item technique for each aspect.

Reliability: Besides test-retest reliability, scale reliability (internal
consistency) is of great importance. This is based on correlation and
determines to what extent the incorporated items (or questions) are measuring
the same underlying construct (latent variable), for example “information“.

Practicability: The instrument should be as economical as
possible, and include everything that is necessary for the measurement of
patient satisfaction (content validity), but no more. To achieve high response
rates (> 60%), questionnaires should be concise and sent within five weeks
after discharge (Saal et al. 2005), with one reminder, if possible.

Patient satisfaction as part of outcome quality has gained great
importance in the past decade. The development of highly standardised, valid
and reliable instruments is a prerequisite to gain plausible data. The
patient's involvement should be an integral part of this process. Results of
single item ratings of overall satisfaction are over-optimistic and do not
represent the true indication of care. Conclusions should only be drawn from
results of well-designed, psychometrically developed instruments.

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